Sigmoid Colectomy
4420444143wRVU: 27.1 — Open sigmoid colectomy with colostomy (Hartmann's-type)44140wRVU: 22.03 — Open sigmoid colectomy with anastomosis44145wRVU: 27.87 — Open sigmoid colectomy with low colorectal anastomosis44213wRVU: 3.41 — Laparoscopic mobilization of splenic flexure (add-on)
Sigmoid diverticulitis [complicated / recurrent] [/ sigmoid colon cancer / sigmoid volvulus / symptomatic diverticulosis]
Same
Laparoscopic sigmoid colectomy with primary colorectal anastomosis [/ with end colostomy (Hartmann)]
[Attending name], MD/DO
[Resident/PA name]
General endotracheal. Nasogastric tube placed. Foley catheter placed.
The patient is a [age]-year-old [male/female] with [recurrent sigmoid diverticulitis / complicated diverticulitis with [fistula / abscess / stricture] / sigmoid colon adenocarcinoma] presenting for elective [urgent] sigmoid colectomy. [Preoperative colonoscopy confirmed [finding].] The risks, benefits, and alternatives were discussed including risk of anastomotic leak, injury to ureter and pelvic nerves, and potential for ostomy, and informed consent was obtained.
The sigmoid colon was [thickened and inflamed / with pericolic abscess / adherent to [bladder / pelvic sidewall / small bowel]]. [A fistula tract was identified between the sigmoid and the [bladder / vagina / small bowel].] [A mass was identified in the sigmoid, [X] cm, consistent with [adenocarcinoma / diverticular phlegmon].] The left ureter was identified and preserved throughout. The rectosigmoid junction was [mobile / with thickening]. The mesentery was [well-vascularized / with significant fat wrapping].
The patient was positioned in modified lithotomy [/ supine] with the arms tucked. Foley catheter and NGT were placed. A surgical timeout was performed confirming patient identity, procedure, and prophylactic antibiotic administration.
Pneumoperitoneum was established to 15 mmHg via [Veress needle / Hasson open technique] at the umbilicus. A 12-mm umbilical port was placed. Three to four additional trocars were placed: [12-mm right lower quadrant, 5-mm right upper quadrant, 5-mm left lateral].
The patient was placed in steep Trendelenburg with left side up. The small bowel was retracted out of the pelvis. The sigmoid colon was identified.
The sigmoid mesentery was incised medially at the sacral promontory, entering the avascular retro-mesenteric plane by medial-to-lateral dissection. The left ureter was identified as it crossed over the iliac vessels and was kept on the posterior peritoneum. The retroperitoneal dissection was carried laterally until the white line of Toldt was visualized from behind.
The inferior mesenteric artery [was divided at its origin with [hem-o-lok clips / vascular stapler] for cancer, preserving the left colic artery / was divided distal to the left colic artery origin for benign disease]. The inferior mesenteric vein was ligated and divided at [the inferior border of the pancreas / at the level of the IMA].
The lateral peritoneal attachments of the sigmoid were divided from the white line of Toldt superiorly. [Splenic flexure mobilization was performed: the gastrocolic ligament was divided and the splenic flexure was taken down to provide a tension-free anastomosis.]
The proximal sigmoid [or descending colon] was divided with a [60-mm blue load] laparoscopic GIA stapler. The dissection was continued distally to the rectosigmoid junction [or upper rectum]. The mesorectum was divided. The rectum was divided with [one / two] [purple / blue load] laparoscopic GIA stapler firings.
A small [Pfannenstiel / left lower quadrant] incision was made and a wound protector was placed. The specimen was delivered, confirming adequate margins. A [25-mm / 29-mm] circular stapler anvil was introduced into the proximal bowel and secured with a purse-string suture. The bowel was returned to the abdomen and the wound protector removed.
Pneumoperitoneum was re-established. The circular stapler was introduced transanally and the anastomosis was performed under laparoscopic guidance, joining the proximal bowel to the upper rectum. The anastomosis was tested by air insufflation under saline submersion; no air leak was identified. Both donuts were inspected and confirmed intact.
[HARTMANN'S VARIANT: A primary anastomosis was not performed given [hemodynamic instability / gross fecal contamination / immunosuppression / poor bowel quality / distal rectal division level too low for safe anastomosis]. Per 2024–2025 evidence, primary anastomosis is safe and preferred in most Hinchey III/IV cases (no difference in mortality or morbidity; superior stoma avoidance rate) — Hartmann's should be reserved for the hemodynamically unstable patient, severe immunosuppression, or technically unsuitable anastomosis. Document the specific indication for Hartmann's. The rectal stump was closed with a [linear stapler] and left in the pelvis. An end colostomy was created in the left lower quadrant.]
Hemostasis confirmed. The abdomen was irrigated. Trocar sites were closed with [0-Vicryl at fascia and 4-0 Monocryl subcuticular]. The Pfannenstiel incision was closed in layers.
None
Sigmoid colon with mesentery sent to pathology, oriented with proximal and distal margins marked.
[X] mL
None / [Jackson-Pratt drain in pelvis near anastomosis]
The patient was taken to the PACU in stable condition. ERAS protocol initiated. Diet advanced per clinical status. Anastomotic leak precautions in place.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Laparoscopic sigmoid colectomy with [primary colorectal anastomosis / end colostomy]
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General; Foley + NGT placed
INDICATIONS: .PTAGE-year-old .PTSEX with *** sigmoid *** presenting for elective/urgent sigmoid colectomy. Risks including anastomotic leak, ureter injury, and ostomy discussed. Consent obtained.
FINDINGS: Sigmoid ***. Ureter identified and preserved. [Fistula: *** to ***.] Anastomosis: rectosigmoid junction, mobile.
PROCEDURE:
Modified lithotomy. Foley + NGT. Surgical timeout. Veress/Hasson at umbilicus. 4 trocars. Steep Trendelenburg. Medial-to-lateral dissection. Left ureter identified at iliac vessels, protected throughout. IMA divided [at origin / distal to left colic] with hem-o-lok/vascular stapler. IMV ligated. Lateral attachments divided. [Splenic flexure mobilized.] Proximal bowel divided with 60 mm blue load GIA. Rectosigmoid divided *** load GIA. Pfannenstiel incision; specimen extracted; margins confirmed. Anvil [25/29 mm] secured in proximal bowel with purse-string. Bowel returned. Circular stapler transanal; anastomosis performed under vision. Air leak test negative. Donuts intact. [Hartmann's: primary anastomosis not performed; rectal stump stapled; end colostomy created LLQ.] Hemostasis confirmed. Closed.
EBL: *** mL
SPECIMENS: Sigmoid colon to pathology (oriented, margins marked)
COMPLICATIONS: None
DISPOSITION: PACU stable. ERAS protocol.
Signed: .ME, .MYDEGREE
.TODAYVariants
Open Sigmoid Colectomy
An open approach was used given [converted from laparoscopic due to dense adhesions / acute presentation / prior abdominal surgery / surgeon preference]. A midline laparotomy was performed. The sigmoid colon was mobilized by incising the lateral peritoneal attachments (white line of Toldt). Medial-to-lateral dissection identified the left ureter before dividing the mesentery. The IMA was ligated as described. The anastomosis was performed as a hand-sewn or stapled end-to-end colorectal anastomosis. Bill 44140 for open approach with anastomosis.
Diverticulitis with Colovesical or Colovaginal Fistula
A colovesical [colovaginal] fistula was identified intraoperatively, confirmed by [preoperative CT / cystoscopy / direct visualization]. The fistula tract was divided at the bladder [vaginal] wall. The bladder defect was repaired in two layers with [3-0 Vicryl]. The sigmoid colon was resected including the fistula-bearing segment. An interposition of omentum was placed between the bladder repair and the colorectal anastomosis. A Foley catheter was left to gravity drainage for [7–10] days postoperatively.
Charting Tips
- Document left ureter identification explicitly. The ureter is at risk during sigmoid mobilization as it crosses anterior to the iliac vessels. Document 'the left ureter was identified at the pelvic brim, dissected away from the mesentery, and kept on the posterior peritoneum throughout the procedure.' Ureteral injury is the primary medicolegal risk in sigmoid surgery.
- Document IMA ligation level. For benign disease (diverticulitis), the IMA is typically divided distal to the left colic artery origin to preserve colonic perfusion to the descending colon. For cancer, high ligation at the aorta is required for adequate nodal clearance. Document which was performed and why.
- Document the air leak test. After stapled circular anastomosis, submerge the pelvis in saline and insufflate air transanally — look for bubbles. Document 'air insufflation test performed; no air leak identified' or describe findings and corrective action taken. A positive leak test should prompt anastomotic reinforcement or diversion.
- For diverticulitis cases, document the operative stage (Hinchey classification if peritonitis present) and the decision to create primary anastomosis vs Hartmann's. The choice between primary anastomosis and Hartmann's should be driven by hemodynamic stability, degree of contamination, and patient factors — document your reasoning.
Billing Tips
- Laparoscopic sigmoid colectomy with anastomosis: 44204 (25.76 wRVU, 90-day global). This is the correct code for laparoscopic resection of the sigmoid colon with primary colorectal anastomosis, regardless of indication (diverticular disease, cancer, volvulus).
- Open sigmoid colectomy with anastomosis: 44140 (22.03 wRVU). Use for open approach or when converted from laparoscopic. Do not bill 44204 for a converted case — bill the open code.
- Open sigmoid colectomy with colostomy (end colostomy without anastomosis): 44143 (27.10 wRVU). Use when a primary anastomosis is not performed and an end colostomy is created. This is the code for Hartmann's procedure (sigmoid resection + end colostomy + rectal stump closure). Note the higher wRVU vs 44140 (27.10 vs 22.03) reflects the additional complexity of colostomy construction.
- Laparoscopic splenic flexure mobilization: 44213 (3.41 wRVU, add-on). Bill in addition to 44204 when splenic flexure mobilization is required to achieve a tension-free anastomosis. Document that splenic flexure takedown was performed as a distinct additional step.
- For sigmoid cancer, the procedure is oncologically similar to a left hemicolectomy with high IMA ligation. Code selection depends on the specific extent of resection — sigmoid-only resection = 44204; resection including descending colon to splenic flexure = 44204 or 44207 depending on extent. Document proximal resection margin level.
- Diverting loop ileostomy created at the same session is separately billable: 44310 (loop ileostomy, 8.69 wRVU) with modifier -51. Document indication for defunctioning.